Healthcare Provider Details

I. General information

NPI: 1356633770
Provider Name (Legal Business Name): NATHAN NITZKY RNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2011
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 E VINEDO LN
TEMPE AZ
85284-1529
US

IV. Provider business mailing address

PO BOX 12401
TEMPE AZ
85284-0041
US

V. Phone/Fax

Practice location:
  • Phone: 602-696-8664
  • Fax:
Mailing address:
  • Phone: 602-696-8664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN111312
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: